DISORDERS AFFECTING SENSORY-PERCEPTUAL FUNCTIONING

1. Hydrocephalus
   • Introduction: Hydrocephalus, known to the layperson as “water on the brain,” is actually a syndrome resulting from disturbances in the dynamics of CSF. The accumulation of this fluid causes enlargement and dilation of the ventricles of the brain and increased intracranial pressure (ICP). If untreated, severe brain damage will result; treatment is a surgical shunting procedure that allows CSF to drain from the ventricles of the brain to another, less harmful area withm the body: jugular vein, right atrium of the heart, or peritoneal cavity. Hydrocephalus can develop as the result of a congenital malformation (e.g., Arnold-Chiari malformation); can be associated with other congenital defects (e.g., spina bifida); or can be acquired secondary to infection (e.g., meningitis), trauma, or neoplasm.
   • Assessment:
     1. Head: increased circumference - earliest sign of hydrocephalus in the infant (more than 1 in/mo).
     2. Fontanels: tense and bulging without head enlargement.
     3. Veins: dilated scalp veins.
     4. "Setting-sun" sign: sclera visible above pupil; pupils are sluggish with unequal response to light.
     5. Cry: shrill, high pitched.
     6. Developmental milestones: delayed.
     7. Reflexes: persistence of neonatal reflexes; hyperactive reflexes.
     8. Feeds poorly.
     9. Signs of increased ICP:
        • Vomiting.
        • Irritability
        • Seizures
        • Decreased pulse.
        • Decreased respirations.
        • Increased blood pressure.
        • Widened pulse pressure.
     10. History may reveal other CNS defects (e.g., spina bifida), infection (e.g., meningitis), trauma, or neoplasm.
   • Analysis/nursing diagnosis:
     1. Altered cerebral tissue perfusion related to increased intracranial pressure.
     2. Impaired skin integrity related to enlarged head size and lack of motor coordination.
     3. Altered nutrition, less than body requirements, related to anorexia and vomiting.
     4. Anxiety related to diagnosis and uncertain outcome.
     5. Knowledge deficit regarding care of the child with a shunt and follow-up care.
   • Nursing care plan/implementation:
     1. Goal: monitor neurological status.
        • Measure head circumference daily, and note any abnormal increase.
        • Perform neurological checks at least every 4 hours to monitor for signs of increased ICP.
        • Report signs of increased ICP stat to physician.
        • Assist with diagnostic procedures/treatments: ventricular tap, computed tomography (CT) scan, etc.
     2. Goal: health teaching to reduce parental anxiety.
        • Do preoperative teaching regarding the shunt procedure: stress need to remove excessive CSF to relieve pressure on brain; done as soon as possible after diagnosis is established.
        • Stress early diagnosis and prompt shunting procedure to minimize the risk of long-term neurological complications.
        • Offer realistic information regarding prognosis:
          1. Surgically treated, with continued follow-up care: 80% survival rate.
          2. Of these survivors, 50% are completely normal and 50% have some degree of neurological disability (such as inattentiveness or hyperactivity).
     3. Goal: provide postoperative shunt care.
        • Position:
          1. Flat in bed for 24 hours, to prevent subdural hematoma.
          2. Gradually increase the angle of elevation of HOB, as ordered by surgeon.
          3. On the unoperative side, to prevent mechanical pressure and obstruction to shunt.
        • Monitor head circumference daily to note any abnormal increase that might indicate malfunctioning shunt.
        • Monitor vital signs; monitor for signs of increased ICP.
        • Monitor for possible complications:
          1. Infection.
          2. Malfunction of shunt: increased ICP.
     4. Goal: provide discharge teaching to parents regarding home care of the child with a shunt.
     • Stress need for long-term follow-up care
     • Discuss feeding techniques, care of skin (especially scalp), need for stimulation.
     • Prepare parents for shunt revisions to be done periodically as child grows.
     • Teach parents signs and symptoms of shunt malfunctioning (i.e., of increased ICP or infection) and to report these promptly to physician.
     • Encourage parents to enroll infant in “early infant stimulation” program to maximize developmental potential.
     • Stress need to monitor development at frequent intervals, make referrals prn.
   • Evaluation/outcome criteria:
     1. Neurological functioning is maintained or improved.
     2. Adequate nutrition is maintained.
     3. No impairment of skin integrity occurs.
     4. Parents’ anxiety is relieved; they verbalize understanding of how to care for child after discharge.